Terry Ormond-Prout explains how osteoarthritis and rheumatoid arthritis impact the underwriting process
Arthritis is one of the biggest causes of disability in the UK, affecting people of all ages, in particular, older people. Over eight million people in the UK are affected, but only one million seek treatment as most suffer no pain or symptoms and do not realise they have arthritis.
Arthritis can affect many joints - polyarthritis; a few joints - oligoarthritis; or just a single joint - monoarthritis, and although there are over 100 types of arthritis, the two most commonly known are osteoarthritis and rheumatoid arthritis.
Osteoarthritis is a disease affecting joints in the body. The surface of the joint is damaged and the surrounding bone grows thicker. This is sometimes also known as degenerative bone disease.
Understanding how osteoarthritis develops requires some knowledge of how joints work. A joint is where two bones meet and the end of the bones are covered by a thin layer of cartilage, which cushions the joint and spreads the forces when pressure or load is put on the joint. The cartilage has a smooth slippery surface that allows the bone ends to move freely. The joint is surrounded by a membrane called the synovium, which produces a thick synovial fluid that helps nourish the cartilage and keep it lubricated.
Inflamed
When osteoarthritis develops in a joint, the cartilage becomes rougher and thinner and the bone beneath becomes thicker. The bone at the edge of the joint starts to grow outwards and form osteophytes - bony spurs. The synovium may produce extra fluid, which makes the joint swell slightly. In severe osteoarthritis, the cartilage can become so thin that it no longer covers the bone ends, which then rub against each other and start to wear away.
No specific cause is known for osteoarthritis, but it is usually found in people in their late 40s. Possible causes or at least contributing factors include:
• Being overweight.
• Previous injury to a joint e.g. fracture.
• Heavy manual occupation.
• Overuse due to sport.
• A congenital abnormality in a joint.
• Joint already affected by another form of arthritis.
• Excessive pressure on a joint.
Rheumatoid arthritis is different to osteoarthritis in the way it attacks the joint. Rheumatoid arthritis makes the joints of the body inflamed. The inflammation takes place within the synovium. The swelling is caused by a build-up of cells and fluid in the synovium.
Rheumatoid arthritis does not just affect the joints. In a few people, other parts of the body such as the lungs and the blood vessels become inflamed. Inflammation in the joints can make some people feel generally ill. Sometimes this leads to overwhelming tiredness or fatigue, which may be more difficult to cope with than the painful joints.
Blood tests
There also may be inflammation in the eyes, which quite often become dry and irritable. Inflammation may also affect the lungs and, occasionally, the membrane around the heart. Rheumatoid nodules may appear. These are fleshy lumps, which usually occur just below the elbows, but may appear on hands and feet as well. They may occur in other places, but this is rare.
Anaemia, the lack of red blood cells in the body, is also very common. It affects about eight out of ten of people with rheumatoid arthritis. Some people with uncontrolled rheumatoid arthritis lose weight, and many complain of hotness and sweating brought on by the inflammation.
There are two kinds of test that may help in confirming the diagnosis of rheumatoid arthritis: blood tests and x-rays.
Blood tests may show a person is anaemic. They may also detect changes in blood caused by inflammation. The original test of this type was called the erythrocyte sedimentation rate (ESR). More recently the plasma viscosity test has been used, and the most recent test is for a protein called C-reactive protein. Each of these may show a high value when inflammation is present.
The 'rheumatoid factor' is another blood protein produced by a reaction in the immune system. About eight out of ten people with rheumatoid arthritis have positive tests for this protein. But its presence does not make the diagnosis certain - about one in 20 people without rheumatoid arthritis also have positive tests.
X-rays can also reveal any damage caused to the joints by inflammation from rheumatoid arthritis. X-rays are usually taken on the feet because the changes caused by rheumatoid arthritis often appear here before they appear in other joints.
Studies into magnetic resonance imaging and ultrasound scanning are currently underway for diagnosing rheumatoid arthritis. These are more sensitive for picking up changes and may be widely used in the future.
Terry Ormond-Prout is life and disability underwriter at Scottish Equitable Protect
The cost of arthritis
• 206 million working days were lost in the UK in 1999-2000.
• £2.4 billion was paid in incapacity benefit in 2001.
• £98 million was paid to people claiming severe disablement allowance in 2001.
• Cost of community and social services was £389 million and £1.3 billion respectively in 2001.
• NHS expenditure on arthritis increased by only 5% between 1990 and 1999, compared with an increase of 19% in the total NHS budget.
• Cost of GP consultations was £307 million in 2000.
• Cost of drugs prescribed was £341 million in 2000.
• Costs of rheumatology in hospitals was £259 million in 2000.
• Cost of hip and knee replacements was £405 million in 2000.
• These costs total £5.5 billion.
Taking note of the above statistics it is not surprising that arthritis crops up on a considerable number of proposal forms.
Source: Arthritis Research Campaign, Arthritis at a glance, Arthritis: The big picture and Swiss Re Life & Health Guide
Underwriting implications
When underwriting osteoarthritis, it is usually split into three categories:
• Mild - minor symptoms, mainly early morning / late evening stiffness, no effect on lifestyle, reasonable range of movement, normal manual dexterity.
• Moderate - more persistent symptoms requiring simple analgesics, some reduction in previous activities/pastimes.
• Severe - regular and persistent pain, limited range of activities, regular use of aids such as a walking stick.
Osteoarthritis in itself would not be a factor for life cover but in severe cases it can be a painful and disabling condition and may give rise to reactive depression. In these circumstances an extra premium may be justified, but for mild and moderate arthritis standard rates would normally apply. Osteoarthritis has no implications for critical illness (CI) and standard rates apply, but for income protection (IP), total and permanent disability (TPD) and waiver of premium, exclusion is always applied except in severe cases where this cover may be declined.
Rheumatoid arthritis because of its systemic nature is underwritten differently, as other organ involvement may occur. Again it can be split into three categories:
• Mild - minimal pain, slight pain or stiffness in peripheral joints, no or minimal swelling and no deformity. No continuous treatment required, physiotherapy and occasional use of aspirin and anti-rheumatic drugs, negative rheumatoid factor, ESR less than 30 mm/hr, ability to carry out all normal activities of daily living (ADLs).
• Moderate - moderate activity, troublesome pain and stiffness, more extensive joint involvement, slight deformity or limitation of movement in affected joints. Frequent or continuous drug therapy. Rheumatoid factor, positive in moderately raised titre. ESR less than 55mm/hr. Able to carry out most or all ADLs with limited difficulty or assistance.
• Severe - chronic active disease, no complete freedom from pain, moderate or marked deformities with serious restrictions of movement and impairment of function. Presence of extra-articular lesions, e.g. nodules, pleural effusion, pulmonary fibrosis, pericarditis. Continuing treatment including steroids. Frequent morbidity. Rheumatoid factor positive in high titre. ESR greater than 55mm/hr. Able to perform few ADLs, requiring significant extra help.
When underwriting rheumatoid arthritis, the possibility of other organ involvement must be taken into consideration, therefore a GPs report is usually requested. Life and CI cover if rheumatoid arthritis is mild can be accepted at standard rates, or if leaning toward moderate, a small rating may be applied. This rating increases if rheumatoid arthritis falls into the moderate category and if severe cover may be declined.
When underwriting disability benefits, the severity of the disease and the definition of disability requested would determine the terms a provider can offer. For IP, TPD and waiver of premium, current statistics indicate that 50% of rheumatoid arthritis patients are work-disabled ten years after onset. The underwriter should consider whether the occupation requires manual dexterity or physical agility and in cases of rheumatoid arthritis in remission, the underwriter should consider the effect of relapse on occupation. For clients with rheumatoid arthritis the deferred period for work related benefits is generally preferred to be 13 weeks or more as 'flare-ups' can cause incapacity for several weeks. Even mild rheumatoid arthritis can incur a rating and this increases as the degree of severity increases. When the client falls into the severe category a decline is most probable.
